I am both happy and nervous to be a student again. Over the past several years, primarily in response to my own experience as a patient, I've become increasingly interested in the field of integrative medicine. Last year I decided to solidify my commitment and expand my knowledge, enrolling in the University of Arizona Integrative Medicine Fellowship, directed by integrative medicine pioneer, Dr. Andrew Weil. I am one of eighty-eight physicians and advanced practice nurses enrolled in the Class of 2018. I am enjoying the material immensely. I'm already incorporating what I've learned into the education of my peers, learners and the care of my patients.

Through personal and professional experience, I've found Western Medicine is good at prolonging life, but the pills and procedures we prescribe often come at the expense of optimum health. Western Medicine is very siloed, and little thought is given to a patient’s health outside of the specialist's silo. Siloed practice, along with specialty specific pharmaceuticals and procedures, may be good at solving individual medical problems, but this approach also causes new issues by throwing a patient's delicate homeostasis off kilter. I've learned health cannot be derived solely from a pill or procedure. Instead, optimal health is derived from the synergistic balance of body, mind and soul.

Allopathic physicians often forget the body has a remarkable ability to heal itself. Through the medicinal use of food, manipulation of the mind-body connection, and use of other complementary techniques, we can positively impact our patient's health. Despite their effectiveness, the interventions of integrative medicine are inexpensive and thus can be used to help us control runaway costs in healthcare.

I've had a lifelong interest in the impact of nutrition on health. I have done extensive reading on macronutrients and vitamins. Most recently, I've become interested in the microbiome, inflammation, and their influence on health. Thus, Andrew Weil's program, with its focus on the anti-inflammatory diet, was naturally attractive to me. I am currently conducting a few studies in this realm including looking at the practices of healthcare and their impact on obesity, and the use prebiotics in perioperative care. I plan many more.

In the two-years of study at University of Arizona, I’m learning about nutrition, ancient therapies such as Chinese and Ayurvedic Medicine, and how to manipulate the mind-body connection. The program was particularly attractive to me because of its focus on anti-inflammatory foods and the manipulation health through diet. In addition, I’m getting to know like-minded physicians and nurses across a broad range of medical specialties. Following my studies, I plan to formalize my commitment by sitting for integrative medicine boards. At the completion of my fellowship, I plan to use my new knowledge to improve the lives of my peers, learners and patients.

It is quite fun (and intimidating) being a student again, but I've found, throughout my life, in order to improve I must leave my comfort zone and pursue new endeavors, no matter how uncomfortable they make me. I will periodically write about my journey into integrative medicine here on my blog.

Depression and anxiety are rampant in healthcare. It seems everywhere I turn there is a story about healthcare worker depression and burnout. A recent meta-analysis in JAMA demonstrated up to 30% of medical residents are clinically depressed (1). Residents are not alone. Although few will admit it, many medical faculty and staff also suffer from stress, anxiety and depression (2).

I am a big fan of Positive Psychology— the field that Martin Seligman created many years ago. In addition to helping people Flourish, I believe the lessons of Positive Psychology will usher in the next age of education in healthcare and beyond. Years ago, as I was learning about the field, I came across an interesting exercise that recommended writing down 3 positive things that happened each day. This simple exercise was found to significantly enhance mood. More recently, this technique has been adopted by courses on resilience training.

Twitter is a worldwide platform. We, in healthcare, have a great deal to be thankful for—although in the stressful, fast-paced environment we often forget. I hope you will join me sharing/tweeting three good things each day that happen to you both in your personal and professional life. Please use hashtag #3GTHC (Three Good Things Healthcare). I look forward to seeing your tweets!

Hipprocrates is credited with the saying: “Let food become thy medicine.” My personal interest in the medicinal (and harmful) properties of food have become nothing less than an obsession.

I just finished the book Salt, Sugar and Fat by Michael Moss. I found the content of the book deeply disturbing. In a nutshell, food is engineered by industry giants not to help people stay healthy, but to maximize company profit. Maximum sales are obtained by engineering food that fools our evolutionary needs and taps into our addiction pathways. In the book I learned about such things as the Bliss Point, an engineering metric that measures the amount of craving induced by a food. I learned about how the food industry slightly reformulate their products to respond to emerging health concerns--giving the appearance of making the food healthier, but often achieving just the opposite.

I learned everything in the commercial food industry—from development to manufacturing to sales is aligned with profit, not health. And it shows. Most of the world’s health problems ranging from obesity to diabetes to inflammatory bowel disease likely have a connection to the "food" these companies produce.

There is little doubt that the vast majority of processed food is bad for human health, yet it is engineered to be highly addictive. Can you think of another substance that was manufactured and sold similarly? Cigarettes.

It shouldn’t surprise you that the largest tobacco companies now run our largest food companies. These mega companies use many of the tactics they honed selling and defending cigarettes to sell food. Many consumers naively think the FDA will keep them safe—assuming that if food is sold in a store, it must be okay. Many foods are not. And the food companies know they're not. Interestingly, many of the food executives interviewed in the book refuse to eat the food manufactured by their own company. That fact alone should be enough to open people’s eyes. One may only hope…..

If you have the remotest interest in the food industry, I highly recommend, Salt, Sugar, and Fat. You'll never look at an Oreo the same way again!

Depression and anxiety are rampant in healthcare. A recent meta-analysis in JAMA demonstrated up to 30% of medical residents are clinically depressed (Mata et al., 2015). Residents are not alone. Although few will admit it, many medical faculty and staff also suffer from stress, anxiety and depression (McCue, 1982). These symptoms can lead to burnout, manifested as: physical and mental exhaustion, depersonalization, cynicism, and low sense of accomplishment (Krasner et al., 2009). Burnout increases the likelihood of substance abuse, stress-related medical problems, marital and family discord, and errors in patient care (Krasner et al., 2009).

Unfortunately, burnout / depression often begin early in training. In a study in 2009, almost 50% of medical students reported signs of burnout (Krasner et al., 2009). This is not surprising given the ever-changing, anxiety-provoking environment of modern medicine, greater regulatory oversight, the changes brought about by the information explosion, and the weighty responsibility of holding human lives in our hands.

Once, about a decade ago, I was working with a transplant surgeon who had been operating non-stop for a 48-hour period. Chatting him up as I often do in the OR, I commented that he must be exhausted. I cited literature I recently read on the performance of Army Rangers when sleep deprived (Ranger's cognitive and physical performance fell precipitously after 16 hours of sustained performance). The surgeon didn’t skip a beat — in extremely colorful language he looked me in the eye and told me he was 10 times tougher than a Ranger! Unfortunately, in medicine, there remains a stigma against admitting vulnerability or asking for help. Many physicians put on a tough face and labor on.

Some practitioners, like the surgeon mentioned above, wear their fatigue as a badge of honor. But many others don’t, and suffer in silence. Many doctors are too scared to speak up. So many of us endured physical and psychological pain during our training, suffering through sleep deprivation and mind-numbing stress with the overlay of patient suffering and the ever present specter of patient death. Over our career, I believe each patient we’re unable to adequately help / cure adds to our psychological toll.

Unfortunately, the stress does not end with training—it endures throughout a physician’s career. With stress a part of our daily lives, one would think we as a profession have developed ways to effectively intervene. Unfortunately, we have not. Few programs make self-care an ongoing part of physician training (Dobkin and Hutchinson, 2013).

I have noticed a lessening of bravado amongst medical practitioners over the past 10 years. I hope this trend continues. Despite the the more frequent acceptance of vulnerability, the issue of stress and suffering endures as this recent blog post, by an anonymous surgeon discusses. Unfortunately, many physicians continue to suffer in silence.

There is a minority of practitioners who feel trainees should be able to endure stress—after all, they did. To those old school practitioners, stress is a right of passage. I strongly disagree. Enduring stress flies in the face of each of the pillars of mental and physical health: sleep, exercise, diet, and stress-management. It’s time to break the cycle.

In modern medical centers, stress management resources are available for trainees, faculty, and staff, but continue to be underutilized. One evidence-based way to break the cycle of stress is using Mindfulness (Buchholz, 2015). Mindfulness is a secular technique based on Buddhist teachings that was popularized by by John Kabat-Zinn for patients with chronic illness.

I’ve been a fan of mindfulness and meditation for close to a decade. I truly wish I had started earlier. I’ve practiced meditation using timers and more recently with meditation-specific apps like Headspace and meditation equipment like the Muse Headband. I’ve found meditation helps me manage my stress and gives me greater focus both in my personal and professional lives. I believe we do a disservice to our learners by not making mindfulness a mandatory and frequent part of training.

For those of you that are still skeptical—there is an ever increasing pool of literature on the benefits of meditation. A large meta-analysis published in JAMA Internal Medicine showed that meditation and mindfulness “resulted in small to moderate reductions of multiple negative dimensions of psychological stress (Goyal et al., 2014).” A study published in Lancet earlier this year, reported that mindfulness-based cognitive therapy (MBCT) is equivalent to antidepressants in halting the reoccurrence of depression (Kuyken et al., 2015) in patients. The two groups – one on medication, one treated with MBCT – had an essentially equivalent relapse rate of depressive illness. In practitioners, a study published in JAMA showed that physicians who participated mindfulness CME program demonstrated improvements in measures of well-being and patient centered orientation to clinical care (Krasner et al., 2009).

Although techniques such as Mindfulness have become more popular both with business and medical practitioners, many in healthcare are resistant to use integrative medicine, no matter the evidence supporting its benefit.

Stress management is one of the pillars of physical and mental health. I believe it’s time for self-management and stress reduction techniques to have a greater role in medicine. First, we have to de-stigmatize the perception of stress, anxiety, and depression in healthcare workers. Additional studies in undergraduate populations (Campisi et al., 2012) demonstrate that stress, regardless of level, is a ubiquitous problem in our learners. Because stress is ubiquitous in our learners, training to manage these emotions should begin early. In medical school, I believe stress management, mindfulness, meditation and other topics in physical and mental health should be introduced alongside anatomy and physiology in the very first weeks of medical school. These topics need to be revisited and reinforced at every transition of a trainee’s career (classroom to clerkship to internship to residency / fellowship, and finally practicing physician).

Only in this way will the use of mindfulness and meditation become ingrained in the fabric of medical care-and alleviate the suffering of countless practitioners and while allowing us to take better care of our patients—and ourselves.

We have exciting findings in one of our recent studies using screen-based simulation for global health. I’ve been grappling whether to submit our paper to a traditional journal (where the content will be locked behind a pay wall) or to an open-access journal (where I pay a fee up front to have the paper freely available to everyone). It is far from a straight forward decision. As I researched where our paper should live, I was sad to realize very little has changed in the publishing world in the last 20 years.

In the 1990’s, I developed an algorithm in an attempt to move peer and quality review onto the fledgeling Web. Back then I knew all the idiosyncrasies of scholarly publication and the peer-review process. I truly believed traditional publishers were doomed unless they radically changed their business models. One key assumption I made in developing my algorithm was the cost of an article would move to 99¢. I spent some time trying to commercialize a business around the algorithm, going as far as pitching the idea to Apple Computer.

The business side of the idea was essentially the iTunes Store for scholarly publication. If you think about scholarly publications using the framework of the iTunes model, Academicians are the artists and musicians of science. My predictions have not yet proven to come true.

The publishers remain insistent on an archaic charge structure-asking $40, $50, or even $60 for a single full-text article. They fail to realize the exorbinant prices force readers to: 1) find alternative, free sources of the full text articles or 2) ignore their article completely and find another data source. If the iTunes model was adopted, few would hesitate to pay 99¢ for an article. We have a long way to go.

I would imagine, when iTunes was starting up and Napster was a its peak, the music industry wondered if people would pay for their music. Far from destroying the industry, in 2013, the iTunes store generated more than $16 billion in revenue. Surely, adopting this type of charge structure, publishers would recover more per article than they do today.

Unfortunately, academic promotion is highly intertwined with traditional publication and encourages the status quo. Academicians are not paid directly for their "art.” Instead, career advancement and tenure is highly dependent on the quality of their work. The quality of work is judged by the prestige of the journal where their articles are published. Academia perpetuates the dysfunction by demanding their faculty prioritize submissions to the highest rated academic journals-those controlled by traditional publishers with a vise-like grip.

For the time being, we’re stuck with existing models. Until there is a radical change in the way academia evaluates faculty for promotion and tenure.

Understandably, traditional publishers are hesitant to change the entrenched models of their multi-billion dollar industry. Publishers would do well to pay close attention to Dr. Clay Christensen’s Innovators’ Dilemma, I believe old-school publication is one disruptive innovation away from annihilation. As an example, traditional publishers continue to print their product on paper. Although this is an incredible waste in the digital age, they do so for two main reasons: 1. to continue to sell advertisements and 2. to limit the number of articles published each month— driving their citation indices higher (the citation index is dependent on the number of citations per article in a two year period). Although important, economics are not the only thing that needs to change. The peer-review system needs to be revamped as well.

The current peer review system is both slow and can be biased. Publishing in a traditional journal can take more than a year from initial submission to publication. In addition, today’s system is set up to favor bias and nepotism. Those most threatened by the advancement of a novel or even revolutionary idea, the scientists that built their reputation on the current paradigm, are the ones most likely to be critiquing publications (or grant proposals). In these scientist's defense, it is only human to be skeptical of a new idea that could negate decades of one's own work.

Science wants to be free. Open-access journals are a step in the right direction. Time to publication tends to be much faster and once published, the manuscript is universally accessible. However, many in academia warn against publishing in open-access journals because of their lower citation indices. This is not surprising-the citation index was developed before the digital age. Twitter, social media, and blogs are challenging existing paradigms of what type of impact a publication has had. It is refreshing to see many new attempts, such as Altmetrics, to redefine the impact of scholarly information in the digital age.

As I read online comments about open-access journals such as PLOS One, many seem critical of their publication rate and volume. Unlike traditional journals, PLoS One reviews only for scientific soundness—not for the impact of the ideas. This makes sense to me in the digital age—science wants to be free, not caught up in peer-review.

As I worked through writing this entry, I've realized I'm leaning heavily toward publishing in an open-access journal (or at least pay for open access of the article). I am doing so primarily to make our findings available to the broadest range of readers possible, especially those in Low and Middle Income Countries. Had I not yet been promoted, I would likely choose a traditional publisher for fear of negatively impacting my promotability. It's time for a change!

Massive Open Online Courses (MOOCs) have taken education by storm. The rise of MOOC popularity has led to several companies attempting to capatilize on the trend. Coursera, along with its competitor EdX, are two of the largest MOOC companies. Although interest in MOOCs has grown, one of banes of MOOC existence is their dismal completion rate. Completion rates are typically low, hovering around 4% or less. The reason for the drop-out rate is multifactorial, but likely includes disatisfaction with the passivity of current MOOC content. Most of today's MOOCs are delivered in a lecture format.

In the Duke University Human Simulation and Patient Safety Center, our team develops screen-based simulation and games-based learning for healthcare. As I wrote in my article, Virtual Environments in Healthcare: Immersion, Disruption, and Flow, I strongly believe screen-based / games-based learning will have a prominent role in the future of healthcare education, training and assessment. Why? Screen-based simulation retains a great deal of the interactivity of mannequin-based simulation with the added advantages of being scaleable, distributable, and analyzable. The combination of advantages will catalyze a new age of interactivity and analytics in MOOCs.

Our plan is to usher in a new chapter in the evolution of MOOCs—adding interactivity that is so sorely lacking in today’s offerings. Ultimately, through interactive content such as ILE@D Stroke, we hope to improve the overall retention and experience of MOOC participants.

I have spent the last few weeks obsessing about getting an e-portofolio site online. I found there are no accepted guidelines for this, but I tried to make due. Although I began with Wordpress, I ended up building the site with Squarespace. I have added the content and layout and plan to update many of the links in the coming weeks.

Unlike my other blogs, wippp.com and simsingularity, on this site I plan to write about issues much more personal to me. Here you will read my musings on life, work, and the world.

Thanks for visiting and I hope you find what you’re looking for. Please don't hesitate to contact me.